Provider Demographics
NPI:1386281186
Name:PARKSIDE EYECARE, PLLC
Entity type:Organization
Organization Name:PARKSIDE EYECARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:JULIE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-824-3181
Mailing Address - Street 1:318 S LITTLER AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-3823
Mailing Address - Country:US
Mailing Address - Phone:405-341-3567
Mailing Address - Fax:405-359-2000
Practice Address - Street 1:318 S LITTLER AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-3823
Practice Address - Country:US
Practice Address - Phone:405-341-3567
Practice Address - Fax:405-359-2000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-30
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200115110AMedicaid